=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083925630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HYLAND PARK EAST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2010
-----------------------------------------------------
Last Update Date | 06/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 881 LIBERTY BLVD
-----------------------------------------------------
City | SUN PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53590-4656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-834-2073
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 881 LIBERTY BLVD
-----------------------------------------------------
City | SUN PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53590-4656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-834-2073
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROPERTY MANAGER
-----------------------------------------------------
Name | ANN SIMONSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-318-1180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 0013255
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------